Título Original: Outcomes of Talar Neck Fractures: A Systematic Review and Meta-analysis.
Autores: Dodd, Andrew MD, Lefaivre, Kelly A. MD.
Fonte: J Orthop Trauma. 2015 Jan 29. [Epub ahead of print]
Comentários: Dr. Alexandre Leme Godoy.
- Professor Colaborador do Departamento de Ortopedia da USP
- Doutorado pelo Departamento de Ortopedia da Universidade de São Paulo
- Pós-doutorado pela Faculdade de Medicina da Universidade de São Paulo
Abstract
OBJECTIVES:
To report the rates of osteonecrosis and subtalar arthritis after talar neck fractures, and to examine if rates have changed over time.
DATA SOURCES:
A systematic review and meta-analysis of the English literature was performed using EMBASE, Medline, CENTRAL, and Cochrane in November 2011, and updated in November 2014.
STUDY SELECTION:
Inclusion criteria were studies examining talar neck fractures that reported talar body osteonecrosis rates as a primary or secondary outcome. Exclusion criteria included case series with <10 patients or >50% pediatric patients, inability to isolate results of talar neck fractures, primary treatment of talar excision or arthrodesis, mean follow-up <3 months, and non-English literature.
DATA EXTRACTION:
Basic information was collected including journal, author, year published, level of evidence, number of fractures, and follow-up length. Specific information collected included fracture classifications, timing of interventions, method of treatment, osteonecrosis rates, subtalar arthrosis rates, and method of diagnosis of osteonecrosis.
DATA SYNTHESIS:
Fixed effects models were used for meta-analysis. The overall event rate of osteonecrosis was calculated and stratified based on Hawkins’ classification of the talar neck fractures. Mean rates of subtalar arthritis were calculated for all studies, and for studies including >2 years follow-up.
CONCLUSIONS:
The overall rate of osteonecrosis was 0.312. Rates for Hawkins’ types I-IV were 0.098, 0.274, 0.534, and 0.480 respectively. The mean rate of subtalar arthritis was 0.49, but increased to 0.81 in studies with >2 years follow up. Complication rates are high in talar neck fractures and patients should be counseled accordingly.
Comentários:
O tratamento da fratura do colo do tálus é ainda um desafio para os cirurgiões ortopédicos devido ao histórico de resultados funcionais ruins e às taxas de complicação. Representam 2% das fraturas dos membros inferiores e são associadas a trauma de alta energia.
O artigo de revisão sistemática mostra, dentre outros achados interessantes, o seguinte:
1. A complicação mais frequente da fratura do colo do tálus é a osteoartrose da articulação subtalar e não a osteonecrose.
2. Os piores resultados estão relacionados a:
a. Grau de energia envolvida/mecanismo de trauma
b. Malalinhamento residual em varo
c. Fratura cominutas
3. Os melhores resultados estão relacionados a:
a. Planejamento pré-operatório com TC
b. Via de acesso dupla
c. Redução adequada
d. Adequado método de osteossíntese (inclusive com uso de placas nas fraturas cominutas)
4. O tempo decorrido entre o trauma e a cirurgia não interfere no resultado clínico, na consolidação e na prevalência de osteonecrose/osteonecrose. Portanto, essa fratura é melhor tratada por equipe treinada e experiente nesse tipo de lesão.